California’s Hub and Spoke System Learning Collaborative Q2 BUILDING A SYSTEM OF CARE FOR PERSONS WITH OPIOID USE DISORDER Gloria Miele, Ph.D., Learning Collaborative Coordinator UCLA Integrated Substance Abuse Programs (ISAP) Mark McGovern, Ph.D., Consultant Stanford University
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California’s Hub and Spoke System Learning Collaborative Q2
BUILDING A SYSTEM OF CARE FOR PERSONS WITH OPIOID USE DISORDER
Mark McGovern, Ph.D., ConsultantStanford University
Agenda
Welcome, introductions
Hub and Spoke Network- Building your system
Treatment appropriateness case presentation
Network building exercise
Instruction to QI measures data gathering, reporting for future sessions, PDSA
Action planning – what’s next, including schedule for ongoing LC sessions
Yuba
Yolo
Ventura
Napa
Tuolumne
Monterey Tulare
Mono
Trinity
Modoc
Tehama
Merced
Sutter
Mendocino
Stanislaus
Mariposa
Sonoma
Marin
Solano
Madera
Siskiyou
Los Angeles
Sierra
LassenShasta
Lake
Santa Cruz
Kings
Kern
Santa Barbara
Inyo
San Mateo
Imperial
San Luis Obispo
Humboldt
San Joaquin
Glenn
San Francisco
Fresno
San Diego
El Dorado
San Bernardino
Del Norte
San Benito
Contra Costa
Colusa
Riverside
Calaveras
Plumas
Butte
Placer
Amador
Orange
Alpine
Nevada
Alameda8
1
2
3
4
5
67
9
11
12
1314
15
16
10 18
17
19
Network # & Hub location Spokes
1 Lake County (1)Mendocino County (2)
Nevada County (1)2 Siskiyou County (2)
Trinity County (1)Del Norte County (1)
3 El Dorado County (1)Placer County (1) Nevada County (1)
4 Butte County (2)Lassen County (1)Tehama County (1)Plumas County (1)
5 Humboldt County (6)6 San Joaquin County (1)
Stanislaus County (1) 7 Contra Costa County (TBD)8 San Francisco County (TBD)9 Sonoma County (1)
Lake County (1)Yolo County (1)Colusa County (1)Napa County (1)
10 Los Angeles County (10) 11 Marin County (8)12 Yolo County (2)
Sacramento County (1)13 Santa Cruz - N County (6)14 Santa Cruz - S County (4)
San Benito County (1)Monterey County (1)
15 Fresno County (TBD)16 Solano County (TBD)17 San Diego County (7) 18 Los Angeles County (10)19 San Bernardino County (1)
Riverside County (6)San Diego County (2)
CA H&SSHubs and Spokes
Learning Collaborative
Online TrainingEBPsProject Echo
Face-to-FaceTraining
EBP SkillsCommunity Forums
TechnicalAssistance
Warm LineSpecific Requests
California Opioid Hub and Spoke ProjectLearning Collaboratives
• Engage H&SS participants in process of shared learning and experience to facilitate implementation of services, assist with procedural changes, and provide opportunities for interactive problem solving
California Opioid Hub and Spoke ProjectCSAM Mentored Learning Experiences
• 72 prescribers will receive scholarships• Mentored learning experiences and CSAM Annual
Conference (Aug. 29-Sept. 1 in San Francisco)• Application process TBA early 2018
CME TopicsYear 1
SESSION 1 The Hub and Spoke Model: Expanding Access to Care
SESSION 2 The Evidence for Addiction Medication in General and Specialty Health Care
SESSION 3 Team-Based Care Using MAT in General and Specialty Practice
SESSION 4 Treatment Response Monitoring
TRADITIONAL SYSTEM OF CAREFOR PATIENTS WITH OPIOID USE DISORDERS
Office-based opioid treatment (OBOTs): With DATA2000, a physician with specialized training can get certified and obtain a “X” on his/her DEA license to prescribe buprenorphine; Recently nurse practitioners and physicians assistants have been given ”X” waiver privileges
Any licensed prescriber can prescribe naltrexone (or hydrocodone, oxycodone, dilaudid or percocet)
“PERFECT STORM”HIGH RATES OF DEATH AND DISEASE BUT SO MANY BARRIERS
OTP barriers
OBOT barriers
System barriers
Presenter
Presentation Notes
Lead discussion. What are the barriers: OTP barriers: Hidden bastions of isolation; Only offer methadone; Difficulty recruiting/retaining workforce; Too few programs; Marginalized (Alanis-Hirsch et al 2016) OBOT barriers: Too much time; Insufficient access to specialists and/or higher levels of care; Outside scope of practice; Patient complexity; Fear of being flooded by demand; Too few prescribers, too few patients per prescriber (Knudsen, 2015) System barriers: No coordination of effort—no one’s problem or job; Patients involved in multiple fragmented systems; Skepticism/doubt about MAT in professional AND recovery communities (Korthius et al, 2016)
HUB & SPOKE MODELTREATING OUD LIKE ANY CHRONIC DISEASE
Unprecedented opportunity thru convergence of opioid overdose epidemic, federal health care legislation (ACA; Parity), population health, & chronic disease management approaches
Addiction medicine and services join mainstream health care
Recognition that some OUD patients are complex and may require a network of health care and social services over the course of their illness
Simplify for patients and families
OTPsHUBS ARE SPECIALITY CARE CENTERS
HUBAssessment
Care CoordinationMethadone
Complex AddictionsConsultation
SpokesNurse-Counselor Teams
w/prescribing MD
SpokesNurse-Counselor teams
w/prescribing MD
CorrectionsProbation &
Parole
SpokesSpokes
Residential Services
In Patient Services
Pain Management
Clinics
Medical Homes
Substance Abuse Out-
Pt Treatment
Family Services
Mental Health
Services
HUBAssessment
Care CoordinationMethadone
Complex AddictionsConsultation
SpokesNurse-Counselor Teams
w/prescribing MD
SpokesNurse-Counselor teams
w/prescribing MD
CorrectionsProbation &
Parole
SpokesSpokes
Residential Services
In Patient Services
Pain Management
Clinics
Medical Homes
Substance Abuse Out-
Pt Treatment
Family Services
Mental Health
Services
OBOTsSPOKES ARE WELL-CONNECTED
Spoke: The ongoing care system comprised of a prescribing physician & collaborating health & addictions professionals who monitor adherence to treatment, coordinate access to recovery supports, & provide counseling,
contingency management, & case management services
Practice Settings
Blueprint Advanced
Practice Medical Homes
Outpatient Substance Use
Treatment Providers
Federally Qualified Health
Centers
Primary Care Providers
Independent Psychiatrists
HUB (OTP) AND SPOKE (OBOT) NETWORKA PATIENT-CENTERED MEDICAL NEIGHBORHOOD
Patient Centered Medical Home (PCMH) vs. Patient Centered Medical Home-Neighborhood (PCMH-N) for complex patients
Focus on whole-person care and minimizing duplication of services, reduced conflict across service providers, better outcomes and patient experience
Care coordination, communication and a common sense of mission
OUR patients (not yours or mine)
Agency for Healthcare Resources and Quality, 2011; Fisher, 2016
SpecialtyCareOTP
Primary CareOBOT
PCMH-N
PATIENT-CENTERED MEDICAL HOME/NEIGHBORHOODADDICTION AS A CHRONIC MEDICAL CONDITION
SERVICES THAT ADDRESS SOCIAL DETERMINANTS
AHRQ OUTLINEDKEY ACTIVITIES FOR PCMH-N SUCCESS
Workflow/workforce: Dedicated care coordination staff
Clearly defined roles about what practices do and don’t do
Clear and documented procedures for consultation or co-management
Metrics for care transitions and intensity
Patient and family engagement & shared decision making
Performance reporting and tracking systems for care coordination
Philosophical shift in perspective
Case Example
CA H&SS TOOLSMETRICS FOR CARE TRANSITIONS AND INTENSITY
Optimal level of care setting, Hub or Spoke Treatment Needs Questionnaire (TNQ)
Adjusting treatment intensity in SpokesOBOT Stability Index
Determining efficacy/comfort range in practice scope
Treatment of OUD Severity Index (TOCI)
18
Determining Setting of Care: Hub or Spoke?
Treatment Needs Questionnaire (TNQ)
OBOT - office based opioid treatment with bup at spoke
OTP is opioid treatment program with methadone or bup at Hub
Required for Hub providers, encouraged for Spoke providers to develop consistent triage screening process
Does not consider ER-Naltrexone
Scores up to 26 with lower scores predicting better OBOT outcomes
• 0-5: Excellent candidate for OBOT• 6-10: Good candidate for OBOT
with integrated behavioral health services
• 11-15: Candidate for OBOT by board certified addiction physician in a tightly structured program with supervised dosing & on-site counseling or in OTP (Hub)
• 16-26: OTP (Hub) candidate (or residential or inpatient)
Scoring
Presenter
Presentation Notes
21 items Maximum score = 26 Higher scores may mean more services or expertise is needed Some items weighed more heavily than others based on research literature and professional experience Not yet validated as predictive by controlled trials
If you have ever been on medication-assisted treatment (e.g. methadone, buprenorphine) before, were you successful?
0 2
Do you have any legal issues (e.g. charges pending, probation/parole, etc)? 1 0
Are you currently on probation? 1 0
Have you ever been charged (not necessarily convicted) with drug dealing? 1 0
Do you have a chronic pain issue that needs treatment? 2 0
Do you have any significant medical problems (e.g. hepatitis, HIV, diabetes)? 1 0
Do you have any psychiatric problems (e.g. major depression, bipolar, severe anxiety, PTSD, schizophrenia, personality subtype of antisocial, borderline, or sociopathy)?
1 0
Do you ever use cocaine, even occasionally? 2 0
Do you ever use benzodiazepines, even occasionally? 2 0
Do you have a problem with alcohol, have you ever been told that you have a problem with alcohol or have you ever gotten a DWI/DUI?
Type Definition InformationPre-Consultation exchange
Expedite/prioritize care; Answer special clinical question; “curbside consultation”
General referral guidelines
Formal consultation Formal consultation visit (1 or a “few”) focused on discrete question
Question/answer, report and recommendation
Co-management optionsShared management of the disease
Specialty provides expert guidance and f/u for 1 specific condition (not day-to-day management)
Ongoing communication on status/progress (Both are responsible but with clear delineation of expectations and roles)
American College of Physicians: Patient-Centered Medical Home – Neighbor Interface (2010)
Supplemental Info: TYPES OF PCMH-N INTERFACENOT SIMPLY ABOUT REFERRAL
Type Definition InformationCo-management (continued)Principal care for the disease
Both PCMH and specialty care are active, specialty care is limited to discrete set of problems; PCMH responsible for all aspects of care and is first contact
Ongoing communication on status/progress (Both are responsible but with clear delineation of expectations and roles)
Principal care of illness for limited time
Specialty care first contact for limited time
PCMH receives ongoing reports, retains input on referrals, and may provide certain other care
Transfer to specialty PCMH-N for entirety
Specialty care becomes medical home (NCQA-PPC-PCMH recognition)
E.g. ID practice for complex HIV/AIDs patient.PCMH receives updates on status/progress
TYPES OF PCMH-N INTERFACENOT SIMPLY ABOUT REFERRAL